HEALTH AND HIV FUNDING
Budget Monitoring Forum
Presenter: Mark Blecher |
National Treasury
| November 2011
Mortality beginning to drop
2
Numbers on AIDS treatment
3
Health personnel
4
Primary care visits
5
National service delivery agreement
Table 1: Summary of outcomes and targets of the NSDA
Outcome
Target for 2014, with baseline values
from 2009
1
Increase life-expectancy
Increase life-expectancy from 53.9 to 58 years
for males and 57.2 to 60 years for females
2
Decrease maternal and child mortality
Decrease maternal mortality rate from 625 to
≤ 100 per 100 000
Decrease under-five mortality rate from 104 to
≤ 20 per 1000
Decrease infant mortality rate from 53 to ≤ 18
per 1000
3
Combat HIV and AIDS and decrease the burden of
Reduce new HIV infections by 50%
disease from TB
Of
all
those
eligible
for
highly
active
antiretroviral therapy (HAART), 80% must have
access to it
Increase TB cure rate from 64% to 85%
4
Strengthen health system effectiveness
Re-engineering of PHC
Implement NHI system
Source: National Department of Health (NDoH), 2010. 2
6
Middle income health financing
7
Health spending
8
Public and private health spending (real)
9
Provincial DOH spending (real)
Real spending growth per annum
Provincial health funding trends R million real 10/11
prices
120,000
100,000
80,000
60,000
R million
40,000
20,000
0
Per capita health spending (real 10/11)
Health spending as % of GDP
Health spending as % of GDP
10.00%
9.00%
8.00%
7.00%
Public h ealth
6.00%
Private
T otal
5.00%
4.00%
3.00%
2.00%
10
Hospital workloads
11
Health infrastructure
Total R10b pa
Improve delivery capacity
R134m for NDOH 11/12
Partnerships with DBSA, CSIR
Managing engineers
Project monitoring tools
Project intervention teams
5 large PPPs
New Health Infrastructure grant
(R1.7b rising to R1.9b)
4,500
4,000
3,500
3,000
2,500
Budget
Expenditure
2,000
Under-exp
1,500
1,000
500
0
03-04
04/05
05/06
06/07
07/08
08/09
09/10
10/11
11/12
12/13
13/14
•
•
•
•
•
•
•
•
•
12
Budget 2012
•
•
•
•
•
•
•
•
Difficult fiscal position
Holding budget – no increase in deficit
Only contingency reserve available for allocation
Function committee approach
Reprioritisation
Non-discretionary areas
Policy priorities (minimal fiscal space)
Savings (partly to fund economic stimulus package, enterprise support,
EPWP type jobs, NHI pilots)
13
Budget 2012
•
•
•
•
•
•
•
•
Difficult fiscal position
Holding budget – no increase in deficit
Only contingency reserve available for allocation
Function committee approach
Reprioritisation
Non-discretionary areas
Policy priorities (minimal fiscal space)
Savings (partly to fund economic stimulus package, enterprise support,
EPWP type jobs, NHI pilots)
14
Fiscal position
15
Government borrowing
16
Health and social protection diagram
National Social Development:
Programme 1,4 &5
R767 million
Women, Children and People
with Disabilities
R63 million
Soc Dev provincial dept.
R12 billion
The Commission on Gender
Equality
R55 million
Health & Social Protection
Function MTEF 2011/12
Social Development &
welfare services
R13 billion
National Development
Agency
R175 million
Road Accident Fund
R17 billion
National Social Development:
Programme 3,excl.SASSA
R101 million
CCOD
R110 million
Compensation Fund and
Reserve Fund
R5 billion
Social Security
R31 billion
National Youth Development
Agency
R398 million
UIF
R10 billion
Public Entities & Agencies:
-SASSA
RAF
-NHLS
-CCOD
-Council for Medical Schemes
-Compensation Fund and Reserve
-Unemployment Insurance fund
-National Development Agency
-National Youth Development Agency
-The Commission on Gender equality
Provincial
Social development PDs
Health PDs
Health CGs
Health & Social Protection
R266 billion
National Departments:
-Health
-Labour
-Presidency
- Social Development
-Defence and Military Veterans
-Women , Children and People with
Disabilities
Council for Medical Schemes
R94 million
National Social Development,
programme 2
R98 billion
NDoH
R1.4 billion
Social Assistance
R104 billion
Health
R118 billion
Health PDs and CGs
R110 billion
SASSA
R6 billion
Defence and Military
Veterans
R3 billion
National health Laboratory
Services
R4 billion
17
Health Baseline
Ex p e n d itu re O u tc o m e s
Ad ju s te d
Ap p ro p ria tio n
2 0 0 8 /0 9
2 0 0 9 /1 0
2 0 1 0 /1 1
6 ,0 3 9 ,0 3 7
7 ,0 8 4 ,3 3 6
7 ,8 1 3 ,3 6 5
H e a lt h
1 ,1 2 0 ,5 5 7
Ad m in is tra tio n
2 4 1 ,0 2 1
H e a lth P la n n in g a n d S ys te m s E n a b le m e n t
1 1 9 ,6 7 3
H IV a n d AID S , TB a n d Ma te rn a l, C h ild a n d
5 0 9 ,0 1 7
P rim a ry H e a lth C a re S e rvic e s
1 0 8 ,6 6 0
H o s p ita ls , Te rtia ry S e rvic e s a n d W o rkfo rc e D e ve lo p m e n t 4 1 ,5 8 7
H e a lth R e g u la tio n a n d C o m p lia n c e Ma n a g e m e n t
1 0 0 ,5 9 9
1 ,3 0 9 ,3 1 2
2 6 9 ,9 2 5
1 1 1 ,6 1 7
5 4 7 ,3 5 4
2 7 3 ,2 9 5
2 ,2 9 1
1 0 4 ,8 3 0
H e a lt h P u b lic E n t it ie s
C MS - C o u n c il fo r Me d ic a l S c h e m e s
N H LS -N a tio n a l H e a lth La b o ra to ry s e rvic e s
2 ,7 4 1 ,5 4 0
5 8 ,2 6 1
2 ,6 8 3 ,2 7 9
D e fe n c e a n d M ilit a r y v e t e r a n s
Milita ry H e a lth S u p p o rt
2 ,1 7 6 ,9 4 0
2 ,1 7 6 ,9 4 0
R th o u s a n d
N a t io n a l
P r o v in c ia l
H e a lt h (In c lu d in g c o n d it io n a l g r a n t s )
Ad m in is tra tio n
D is tric t H e a lth S e rvic e s
E m e rg e n c y Me d ic a l S e rvic e s
P ro vin c ia l H o s p ita l S e rvic e s
C e n tra l H o s p ita l S e rvic e s
H e a lth S c ie n c e s a n d Tra in in g
H e a lth C a re S u p p o rt S e rvic e s
H e a lth F a c ilitie s Ma n a g e m e n t
Min u s th e NHLS d o u b le c o u n t
To t a l
7 2 ,3 7 2 ,8 5 5
7 5 ,0 5 6 ,1 3 4
2 ,6 3 8 ,3 9 7
3 1 ,4 7 7 ,9 0 4
2 ,8 9 9 ,3 8 4
1 7 ,4 7 5 ,7 5 4
1 0 ,9 9 9 ,6 3 2
2 ,5 8 6 ,1 6 4
1 ,2 1 4 ,4 5 4
5 ,7 6 4 ,4 4 5
2 ,6 8 3 ,2 7 9
7 8 ,4 1 1 ,8 9 2
Ave ra g e
g ro w th fo r
MTEF
p e rio d
1 1 /1 2 to
1 4 /1 5
5 .0 %
2 0 1 2 /1 3
2 0 1 3 /1 4
2 0 1 4 /1 5
8 ,1 7 1 ,1 5 3
8 ,4 4 7 ,4 4 4
8 ,9 2 9 ,7 5 2
9 ,4 5 0 ,7 6 6
0 8 /0 9 to
1 1 /1 2
1 0 .6 %
1 ,4 0 3 ,6 9 9
1 2 4 ,5 0 2
2 2 3 ,2 2 3
6 1 6 ,8 7 1
1 4 2 ,9 3 0
7 2 ,9 5 0
2 2 3 ,2 2 3
1 ,4 2 3 ,0 9 5
3 2 6 ,0 7 1
1 6 0 ,3 8 7
5 3 3 ,5 6 6
1 3 9 ,6 3 2
9 8 ,3 8 1
1 6 5 ,0 5 8
1 ,4 8 7 ,7 0 4
3 2 5 ,3 2 4
1 7 7 ,5 5 9
5 5 2 ,4 6 1
1 4 3 ,0 3 2
9 3 ,9 1 2
1 9 5 ,4 1 6
1 ,5 6 4 ,0 7 2
3 4 4 ,3 8 9
1 8 9 ,3 4 7
5 8 1 ,5 6 2
1 5 0 ,1 2 6
9 5 ,1 2 7
2 0 3 ,5 2 1
1 ,6 5 8 ,1 7 4
1 9 5 ,9 2 2
3 1 4 ,7 3 4
6 1 6 ,4 5 6
1 5 9 ,1 3 4
9 5 ,5 3 5
3 1 4 ,7 3 4
8 .3 %
1 0 .6 %
1 0 .3 %
1 .6 %
8 .7 %
3 3 .2 %
1 7 .9 %
5 .2 %
-1 5 .6 %
2 5 .2 %
4 .9 %
4 .5 %
-1 .0 %
2 4 .0 %
3 ,1 6 6 ,8 9 6
6 4 ,3 5 8
3 ,1 0 2 ,5 3 8
3 ,3 6 0 ,0 9 7
8 2 ,2 1 9
3 ,2 7 7 ,8 7 8
3 ,7 0 3 ,9 1 9
9 4 ,0 4 0
3 ,6 0 9 ,8 7 9
3 ,6 3 1 ,7 0 4
1 0 0 ,3 8 7
3 ,5 3 1 ,3 1 7
3 ,8 4 6 ,0 0 5
1 0 5 ,9 0 8
3 ,7 4 0 ,0 9 7
4 ,0 6 1 ,7 3 7
1 1 1 ,2 0 4
3 ,9 5 0 ,5 3 3
1 0 .5 %
1 7 .3 %
1 0 .4 %
3 .1 %
5 .7 %
3 .1 %
2 ,6 0 8 ,1 2 8
2 ,6 0 8 ,1 2 8
3 ,0 4 9 ,5 6 9
3 ,0 4 9 ,5 6 9
3 ,0 4 4 ,1 3 9
3 ,0 4 4 ,1 3 9
3 ,3 2 8 ,0 3 6
3 ,3 2 8 ,0 3 6
3 ,5 1 9 ,6 7 5
3 ,5 1 9 ,6 7 5
3 ,7 3 0 ,8 5 6
3 ,7 3 0 ,8 5 6
1 1 .8 %
1 1 .8 %
7 .0 %
7 .0 %
1 0 6 ,4 2 0 ,6 6 3 1 1 4 ,8 7 3 ,4 0 6 1 2 3 ,0 3 1 ,4 6 4 1 3 0 ,4 2 7 ,3 2 2
1 1 0 ,0 3 0 ,5 4 2 1 1 8 ,4 0 4 ,7 2 3 1 2 6 ,7 7 1 ,5 6 1 1 3 4 ,3 7 7 ,8 5 5
3 ,2 0 4 ,9 4 4
3 ,5 4 3 ,0 8 7
3 ,6 9 7 ,4 7 6
3 ,9 1 9 ,3 2 5
4 7 ,4 3 8 ,2 0 4
5 1 ,7 4 7 ,3 5 8
5 6 ,4 2 9 ,2 0 2
5 9 ,8 1 4 ,9 5 5
4 ,5 3 8 ,3 0 9
4 ,8 5 9 ,3 5 5
5 ,0 8 8 ,5 8 9
5 ,3 9 3 ,9 0 4
2 3 ,4 0 7 ,6 3 0
2 5 ,0 2 1 ,2 2 8
2 6 ,7 4 6 ,1 7 5
2 8 ,3 5 0 ,9 4 5
1 6 ,6 2 7 ,7 2 5
1 7 ,8 6 2 ,5 4 5
1 8 ,9 0 2 ,7 0 0
2 0 ,0 3 6 ,8 6 2
3 ,6 9 2 ,9 3 6
3 ,8 4 5 ,0 4 2
4 ,0 4 3 ,6 8 3
4 ,2 8 6 ,3 0 4
1 ,7 5 9 ,1 3 9
1 ,8 5 1 ,3 7 0
1 ,9 1 5 ,3 8 6
2 ,0 3 0 ,3 0 9
9 ,3 6 1 ,6 5 4
9 ,6 7 4 ,7 3 9
9 ,9 4 8 ,3 4 9
1 0 ,5 4 5 ,2 5 0
3 ,6 0 9 ,8 7 9
3 ,5 3 1 ,3 1 7
3 ,7 4 0 ,0 9 7
3 ,9 5 0 ,5 3 3
1 1 4 ,5 9 1 ,8 1 6 1 2 3 ,3 2 0 ,8 5 0 1 3 1 ,9 6 1 ,2 1 6 1 3 9 ,8 7 8 ,0 8 8
1 3 .6 %
1 3 .6 %
6 .7 %
1 4 .7 %
1 6 .1 %
1 0 .2 %
1 4 .8 %
1 2 .6 %
1 3 .1 %
1 7 .5 %
1 0 .4 %
1 3 .5 %
6 .9 %
6 .9 %
6 .9 %
8 .0 %
5 .9 %
6 .6 %
6 .4 %
5 .1 %
4 .9 %
4 .0 %
3 .1 %
6 .9 %
8 5 ,5 1 6 ,2 0 5
9 4 ,8 1 9 ,0 7 9
8 8 ,6 1 8 ,7 4 3
9 8 ,0 9 6 ,9 5 7
3 ,4 2 1 ,9 2 2
2 ,7 1 0 ,6 8 6
3 7 ,1 9 0 ,8 2 2
4 2 ,7 2 2 ,7 1 7
3 ,4 7 9 ,0 4 5
3 ,8 8 2 ,4 6 0
2 0 ,3 3 5 ,8 2 3
2 2 ,7 5 3 ,3 0 4
1 3 ,2 0 1 ,6 8 7
1 4 ,6 7 0 ,2 2 7
2 ,9 5 4 ,2 2 2
3 ,3 5 8 ,9 8 1
1 ,3 3 0 ,6 1 4
1 ,4 1 8 ,0 3 2
6 ,7 0 4 ,6 0 8
6 ,5 8 0 ,5 5 0
3 ,1 0 2 ,5 3 8
3 ,2 7 7 ,8 7 8
9 2 ,6 0 0 ,5 4 1 1 0 2 ,6 3 2 ,4 4 4
2 0 1 1 /1 2
Me d iu m -te rm e x p e n d itu re e s tim a te s
Ave ra g e
g ro w th fo r
h is to ry
p e rio d
18
Reprioritisation
•
•
•
•
•
•
•
•
•
•
Very difficult fiscal climate requires reprioritisation
Focus on efficiency, improving value for money
Wider call to restructure expenditure
Huge variability in unit costs across hospitals of similar type, districts,
economic classification
Was supposed to be first step of budget process
Not much progress made in Function group in this area
Only significant proposal was to top-slice R200m from HIG and HRG for
nursing college upgrading
Some potential within goods and services area (procurement, arv prices,
fraud, collusion leading to higher prices, improved controls, protocols);
inefficiencies in capital projects
More reprioritisation is required given fiscal position, personnel
pressures, cuts exercise and improving efficiency
Each province will need to look at this in finalising budget for 2012/13
19
Budget bids – NHI Pilots
• Various aspects of NHI need to be tested and piloted
• PHC reforms:
1. Family health teams: ward based teams set up to improve
primary health care delivery
2. District specialist support teams: Aims to strengthen district
health services
3. School health services: Package of health services (e.g.
testing, prevention, deworming) offered at schools
• Contracting with private providers: review legal aspects of
contracting with private GPs, determine how these contracts can be
designed, measured and monitored, and experimentation with
reimbursement mechanisms (e.g. capitation)
• Costing still in progress: Initial rec xxx
1
Non-discretionary areas
Certain pressures are effectively non-discretionary
– ICS (6.8% vs 5.5% carry-through)
– ARV uptake increases (approximately 400 000 pa)
– Possibly rising PHC visits (4-5m pa average over past decade)
21
HIV and AIDS
•
ART Programme: new cd4 350 threshold generalised
– Need to make provision for at least 400 000 growth pa
– Unit cost R4300-R4900 per capita
– Analysis suggests baselines largely sufficient (R1.8b growth pa)
except outer year
– Recommendation xxx
• New NSP development – implications for other sectors
22
Primary health care and volume adjustment:
Rising PHC visits
•
•
•
•
PHC visits rising by 4 mil pa
Possible volume adjustment for
outer year as non-discretionary
baseline adjustment
Transfer as part of new NHI
conditional grant
Links to PHC policies of family
health teams, ward based
community teams, district
support teams and school
health services
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Limpopo
Mpumalanga
Northern Cape
North West
Western Cape
Grand Total
00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10
14,339,786 14,383,889 13,746,488 14,503,175 15,312,880 14,618,214 16,589,065 16,606,276 17,796,107 18,647,433
5,069,882 5,446,065 5,725,472 5,972,199 6,031,495 5,912,089 5,932,312 5,903,854 6,460,991 6,536,325
10,649,014 11,094,574 12,012,319 12,396,325 13,059,604 14,162,418 14,961,820 16,261,089 19,372,439 19,636,757
15,315,661 16,908,055 18,000,507 18,948,993 19,428,937 19,789,376 18,703,020 22,309,763 24,498,906 26,088,177
10,984,360 11,748,869 13,680,318 14,381,591 15,253,259 14,862,213 14,063,129 13,684,125 14,784,386 15,145,254
3,953,523 5,100,122 5,399,366 6,063,243 6,193,706 6,792,927 6,923,114 7,388,645 7,923,291 7,959,887
1,931,154 2,010,410 2,124,661 2,420,212 2,332,201 2,175,354 2,267,522 2,828,567 3,511,999 3,434,203
8,237,237 9,039,665 8,892,998 8,768,182 9,668,768 9,822,014 8,029,057 7,804,490 8,574,971 8,321,827
11,426,477 11,839,414 12,856,051 12,877,078 13,593,636 13,623,772 13,126,182 13,291,336 14,979,546 15,792,199
81,907,093 87,571,063 92,438,180 96,330,998 100,874,486 101,758,377 100,595,221 106,078,145 117,902,636 121,562,061
23
Policy priorities
•
•
•
•
•
NHI pilots
Nursing college upgrading
Office of Standards compliance
Planning large PPPs and infrastructure support
HR strategy
24
NHI
• Key theme for Budget 2012/13
• Release of Green paper, public announcements by Ministers, wide
media coverage and public interest
• Need to chart practical way forward
• DG Health requested NHI pilots as key priority for Budget 2012/13
• Need to accept that NHI will entail greater national control over sectoral
funding
• Need to establish functioning interim mechanism prior to NHI Fund
• Probable establishment of new transitional NHI grant – need to finalise
funding mechanism
• Two other cgs (NTSG, HIV) potential slight renaming to indicate longer
term shift into NHI
25
Infrastructure
• Ministers driving new approach to health infrastructure with larger direct
role for National Department and DBSA
• Nursing colleges upgrading and recapitalisation is immediate focus –
• Large PPPs in planning (but feasibility studies not yet complete)
• New Schedule 7 (in-kind) grant is proposed as option / test case on
nursing colleges upgrading
• Preconditions: i) Provincial sign-off ii) Signed agreements
• Reprioritisation: Nursing college upgrading to be funded initially through
top-slicing of HIG/HRP
• DBSA and CSIR IUSS support interventions
• Efficiency of infrastructure delivery: AG Report and Scopa hearing
26
HR Strategy and ICS for health
•
•
•
•
•
•
•
Development and implementation of the new HR strategy for health
100 page document, draft policy and models released
Large focus on filling posts and increasing supply
Partly via NHI pilots
ICS increase 1.3% estimated to cost R800m pa
Over-spending on health personnel >R1bil pa for several years
Over-spending projection on personnel going forward
27
Provincial Health budget baselines
28
HIV conditional grant health baseline
Rmil
04/05
ec
fs
gt
kz
lm
mp
nc
nw
wc
tot
05/06
99
70
134
186
77
54
32
71
58
782
161
96
207
240
94
90
58
105
93
1,144
06/07
218
142
253
344
176
107
69
142
116
1,567
07/08
233
154
400
467
201
121
74
156
201
2,006
08/09
301
190
577
757
233
187
91
246
266
2,849
09/10
426
298
890
1,036
402
236
110
370
376
4,143
10/11
691
434
1,278
1,499
515
384
182
476
554
6,012
11/12
864
530
1,621
1,889
625
490
213
599
661
7,493
12/13
13/14
1,014
1,222
622
751
1,934
2,294
2,246
2,675
734
884
578
694
247
302
706
849
743
935
8,825
10,607
29
HIV/AIDS subprogramme Health (Health)
R million
Eastern Cape
Free State
Gauteng
KwaZulu Natal
Limpopo
Mpumalanga
Northern Cape
North West
Western Cape
Total
05/06
182
109
368
528
103
106
53
120
172
1,741
06/07
310
152
429
704
207
134
74
197
249
2,456
07/08
357
170
580
1,059
205
195
81
244
240
3,130
08/09
396
214
707
1,239
257
225
113
332
269
3,753
09/10
479
326
1,037
1,535
414
347
149
479
384
5,149
10/11
789
484
1,517
1,611
526
409
221
602
555
6,714
11/12
884
581
1,912
1,925
625
505
247
696
661
8,035
12/13
13/14
1,112
1,314
682
813
2,418
2,910
2,330
2,774
734
884
626
745
283
340
807
852
743
935
9,735
11,568
30
Provincial IYM Sept 11 (6 months of 11/12)
Projection
Available
Province budget
EC
14,237,249 14,485,025
FS
6,820,708
6,944,216
GT
22,837,577 24,156,622
KZN
24,507,254 24,685,811
LIM
11,587,901 12,014,843
MPU
7,365,135
7,213,896
NC
2,946,839
3,072,265
NW
6,322,945
6,650,467
WC
13,395,060 13,393,628
Tot
110,020,668 112,616,773
Spending % spend Deficit
by
September
7,484,979
52.6% -247,776
3,219,779
47.2% -123,508
11,310,740
49.5% -1,319,045
11,728,040
47.9% -178,557
5,894,931
50.9% -426,942
3,291,162
44.7%
151,239
1,411,654
47.9% -125,426
3,005,416
47.5% -327,522
6,268,554
46.8%
1,432
53,615,255
48.7% -2,596,105
31
Estimate of national HIV spend
Rand million
National DOH Total
DOH core
DOH conditional grants
Provincial own dedicated
Education grant
Social services
Sub-total
Treatment of opportunistic infections
Donor
Total
04/05
05/06
06/07
07/08
08/09
09/10
10/11
11/12
12/13
13/14
1,107
1,512
2,026
2,474
3,078
4,868
6,621
7,975
9,344
11,154
372
362
410
467
493
492
569
482
520
547
735
1,150
1,616
2,006
2,585
4,376
6,052
7,493
8,825
10,607
412
542
762
911
1,124
772
663
542
911
961
134
136
144
158
168
177
188
199
209
221
128
223
339
452
607
678
795
843
894
938
1,781
2,413
3,271
3,995
4,977
6,496
8,267
9,559
11,358
13,274
4,477
4,701
4,936
5,183
5,442
5,714
6,000
6,300
6,615
6,946
3,731
3,918
4,114
4,319
4,535
4,762
5,000
5,250
5,513
5,788
9,990
11,032
12,320
13,497
14,954
16,972
19,267
21,109
23,485
26,008
32
NASA draft: Total Funding & Sources for
HIV/AIDS/TB in SA (2007/08-2009/10) (incl % of the Child
Support Grant)
33
Conclusion
• Budget 2012/13 is being formulated in very tough fiscal climate
• Budgets going forward will not be as strong as growth over past three
years
• Very small number of additional allocations from contingency reserve
• NHI pilots will be important going forward and plans will need to become
very practical in year ahead
• Need to finalise whether will or will not have two new conditional grants
– NHI
– S7 nursing colleges grant
• Provinces will need to focus substantially on reprioritisation
• Control of personnel spending will be nb noting projected shortfall
• Increasing efficiency and delivery on capital expenditure
34
NASA draft: Total SA HIV/AIDS Spending
Activities (2007/08-2009/10)
.
35